Indiana Council Partner Program - Indiana Council of Community Mental Health Centers (Indiana Council)

Thank you for your interest in Indiana Council’s partner program. Your partnership is effective for one year beginning the date your application is processed. Please, complete the membership application below. (Updated Nov 2022)

Company Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Website / URL *

Phone *

Organization Email *

Primary Organization Description *

Please list a description of your organization’s services or products. (limited to 200 words)

Membership Classification

Choose your organization’s membership type *

Partner Level: $3,000
Associate Level: $4,000
Executive Level: $6,000

WBE/MBE

Please provide your WBE/MBE certification number or your 501 c 4 tax identification code

REPRESENTATIVES

Each organization may have two representatives on ICCMHC’s communication list.

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Please upload a copy of your logo here

Click or drag a file to this area to upload.

Valid formats: .jpg, .png, .gif